Towards a biological and personalised management of caries

The traditional approach to the carious lesion is giving way to a paradigm focused on biology and tissue preservation: the concept of minimal intervention dentistry. In the dental practice, this evolution requires moving away from systematic operative procedures to favour personalised management, structured around validated protocols such as CAMBRA, MIOC or CariesCare 4D. The clinical challenge now lies in the strategic integration of ion-releasing biomaterials (IRB) capable of triggering an active biological response upon contact with oral fluids.

This study aims to provide a rigorous decision-making framework by classifying clinical interventions into three levels of criticality: non-invasive, micro-invasive and invasive. The objective is to structure the use of bioactive products to stabilise collagen, buffer the pH and promote remineralisation, thus supporting oral eubiosis in the long term.

The central hypothesis of this work posits that modern caries management must imperatively combine individual risk assessment and lesion activity with the targeted use of IRB materials. This "Bioactive Dental Concept" suggests that material selection must no longer be passive, but become a therapeutic lever capable of forming apatite and protecting the integrity of the dentine-pulp complex.

Methodology: A minimal intervention clinical protocol

This study defines an operational framework based on the "Bioactive Dental Concept", integrating the principles of minimum intervention oral care (MIOC). The methodology relies on a systematic classification of clinical procedures into three distinct categories: non-invasive interventions (home care and professional applications), micro-invasive (sealants, resin infiltration, peptides) and invasive.

The decision-making process is structured around the evaluation of three critical clinical parameters:

• The presence or absence of cavitation.
• The activity status of the carious lesion.
• The accessibility and cleansability of the lesion.

The decision-making protocol favours the use of advanced diagnostic technologies, particularly fluorescence and infrared imaging, to guide selective excavation. The choice of materials strategically focuses on ion-releasing biomaterials (IRB), such as "alkasites" and ABRAM (Advanced Bioactive Restorative Adhesive Material) bioactive composites, capable of releasing calcium, phosphate and fluoride ions.

Analysis and management are based on the validated ICCMS™, CAMBRA and CariesCare 4D frameworks, aiming to modulate the biofilm and promote tissue remineralisation while preserving the integrity of the dentine-pulp complex.

The Bioactive Dental Concept Framework

This analysis defines the bioactive material along two axes: Hench's definition (formation of an apatite layer upon contact with biological fluids) and the modern dental perspective. Ion-releasing materials (IRB) are distinguished by their ability to release calcium, phosphate and fluoride, acting as mineralisation vectors.

The study highlights that decision-making relies on the integration of validated protocols such as CAMBRA, MIOC and CariesCare 4D. These models allow for a longitudinal assessment of individual caries risk. A critical point is identified: in patients with a high caries risk, the absolute priority is the modulation of the risk profile before any definitive operative decision.

• Ion release: IRBs promote the formation of an interdiffusion zone at the tooth-material interface.
• Buffering effect: Ability to maintain a favourable pH to limit collagen degradation.
• Instrumentation: The use of suitable sonic or ultrasonic inserts is recommended to preserve healthy structures.

The approach favours the use of fluorescence and infrared imaging diagnostic technologies for early detection, enabling targeted and less invasive interventions.

The era of active biomaterials: a paradigm shift

This study redefines the role of restorative materials: they are no longer simple inert substitutes, but active therapeutic vectors (IRB - Ions Releasing Biomaterials). The clinical significance is major: by releasing calcium, phosphate or fluoride, these materials promote remineralisation and stabilise collagen. The use of sonic or ultrasonic instrumentation, with inserts adapted to the cavity morphology, allows for maximum preservation of healthy tissues, aligning with the CAMBRA or CariesCare 4D concepts.

The departure from the traditional approach lies in the acceptance of clinical pragmatism over the strict hierarchy of Evidence-Based Dentistry (EBD). The study emphasises that innovation, notably "alkasite" type materials or ABRAM adhesives, sometimes outpaces high-level clinical evidence. Waiting decades for long-term follow-up could deprive patients of immediate biological benefits, such as the pH buffering effect limiting caries recurrence.

The limitations of the study are, however, explicit: no current material is yet biologically "ideal". Selection must remain rigorous, based on individual caries risk and lesion activity. Unlike conventional composites, bioactive materials require specific management of the gingival margins, especially where enamel is absent, to ensure the integrity of the dentine-pulp complex.

Conclusion

The transition from restorative dentistry to bio-interactive dentistry requires the integration of ion-releasing materials into a comprehensive tissue preservation strategy.

Summary of results

The study validates the integration of ion-releasing materials (IRB) into a personalised care strategy, classifying interventions from non-invasive to invasive. These biomaterials, capable of forming apatite upon contact with biological fluids, act by buffering the pH and protecting collagen from degradation.

In practical terms, for the practitioner:

• Rebalance before restoring: For patients with a high caries risk, prioritise modulating the risk profile (diet, hygiene) before any definitive restoration to ensure the longevity of the treatment.
• Prioritise sonic instrumentation: Use sonic or ultrasonic inserts adapted to the cavity morphology; they enable selective preparation that preserves healthy tissue while ensuring an optimal peripheral seal.
• Select the IRB at the gingival margins: In the absence of bondable enamel at the gingival level, opt for bioactive materials (such as alkasite or dual-cure composites) to create a protective interdiffusion zone against secondary caries.

Glossary of the bioactive approach

ABRAM (Advanced Bioactive Restorative Adhesive Material): The new guard of adhesives. These advanced restorative materials are no longer simply inert; they interact dynamically with tissues to stabilise the tooth-material interface.

MIOC (Minimum Intervention Oral Care): The foundation of modern dentistry. This clinical framework prioritises maximum tissue preservation based on a longitudinal and personalised assessment of caries risk.

IRB (Ion-releasing biomaterials): "Ion donors". These biomaterials release calcium, phosphate or fluoride to promote remineralisation, buffer the pH and inhibit bacterial proliferation.

Alkasite: An emerging category of bioactive restorative materials (often dual-cure). They are distinguished by their enhanced ion release capacity, ideal for securing extensive restorations.

Eubiosis: The ideal biological balance. In this concept, intervention is no longer aimed solely at mechanical repair, but at the maintenance of a healthy oral microbiota and a non-cariogenic biofilm.

CAMBRA (Caries Management by Risk Assessment): The clinical management tool. This protocol enables the intervention (invasive or non-invasive) to be calibrated based on the patient's specific risk profile rather than the lesion alone.

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